BILATERAL SPIGELIAN HERNIATREATED BY DOUBLE MESH

Abstract

Spigelian hernia is an uncommon variety of abdominal hernias. It has been traditionally treated by tension-free mesh hernioplasty. We report a rare case of a bilateral Spigelian her-nia in an elderly male that was treated by bilateral mesh hernia system. Rare ventral hernia such as Spigelian hernia with weak abdominal wall can be safely treated by tension-free mesh repair using bilayered mesh system. RIASSUNTO L'ernia di Spigelio è una varietà non comune di ernie addominali. tradizionalmente il trattamento è quello da ernio -plastica tension-free. Noi riportiamo un caso raro di un'ernia di Spigelio bilaterale in una donna anziana trattata con appo -sizione Bilaterale double mesh. L'Ernia ventrale e rara come ernia di Spigelio in presenza di un debole muro addominale può essere trattata con successo apponendo una mesh tension-free usando bilayered protheis.

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SUMMARY
Spigelian hernia is an uncommon variety of abdominal
hernias. It has been traditionally treated by tension-free mesh
hernioplasty. We report a rare case of a bilateral Spigelian her-
nia in an elderly male that was treated by bilateral mesh hernia
system. Rare ventral hernia such as Spigelian hernia with weak
abdominal wall can be safely treated by tension-free mesh
repair using bilayered mesh system.
Key words: Spigelian hernia, surgical mesh, ventral
RIASSUNTO
L'ernia di Spigelio è una varietà non comune di ernie
addominali. tradizionalmente il trattamento è quello da ernio -
plastica tension-free. Noi riportiamo un caso raro di un'ernia
di Spigelio bilaterale in una donna anziana trattata con appo -
sizione Bilaterale double mesh. L’Ernia ventrale e rara come
ernia di Spigelio in presenza di un debole muro addominale
può essere trattata con successo apponendo una mesh tension-
free usando bilayered protheis.
Parole chiave: Ernia di Spigelio, mesh chirurgico, ventrale
Acta Chirurgica Mediterranea, 2007, 23: 51
BILATERAL SPIGELIAN HERNIATREATED BY DOUBLE MESH
ANTONINO GRAZIANO - MARCO SANTANGELO - DANILO SAVIO DOMENICO UMANA - RICCARDO LEGGIO
University of the Studies of Catania - Department of Surgery - Hospital and Research Centre - Policlinico - (Head: Prof. A. Licata)
[Ernia di Spigelio bilaterale tratata con double mesh]
Introduction
Spigelian hernias are ventral hernias occurring
through the Spigelian fascia along Spieghel’s semi-
lunar line(1).
They lie under the external oblique aponeuro-
sis lateral to the outer border of the rectus abdomi-
nis muscle.
They commonly occur at a level referred to as
the ‘Spigelian hernia belt’ which is a transverse
band between the level of the umbilicus and the line
joining both anterior superior iliac spines( 2 ) .
Although many cases of unilateral Spigelian hernia
have been reported in the literature, bilateral adult
Spigelian hernias are rarely seen. We report a bila-
teral huge Spigelian hernia that was repaired with
double mesh hernia system.
Case report
A85-year-old women presented with a history
of bilateral lower abdomen swelling and dull aching
pain for 5 years. Abdominal examination revealed
bilateral smooth infra-umbilical bulge lateral to the
rectus abdominis muscle with positive cough
impulse.
An ultrasound of the parietal wall was sought
which reported the swelling to be a bilateral
Spigelian hernia. The patient had no history of pre-
vious abdominal surgery.
Operative technique
The procedure was conducted under general
anaesthesia. The hernias were approached by two
separate transverse incisions at the level of the ante-
rior superior iliac spine, at the lateral border of the
rectus muscle and extending 5-7 cm laterally. T h e
external oblique aponeuroses were opened along
the direction of the fibers.
Herniae were present on either side, lateral to
the rectus sheath from defects in transverses abdo-
minis and internal oblique muscles. The intact sacs
were carefully separated from the margins of the
defect and a pre peritoneal space was developed all
around the defect. A bilayered mesh hernia system
was used to repair the defect with the underlay
patch positioned in the pre peritoneal space.
Few circumferential stitches were used to fix
the underlay mesh and the pre peritoneal fascia.
The onlay patch was positioned above the internal
oblique muscle and sutured to the internal oblique

aponeurosis over the superior, medial and superior
lateral borders and the inguinal ligament over the
inferior lateral border.
The connector was positioned to act as a plug
in the parietal wall defect. The external oblique
aponeurosis was closed over a suction drain. T h e
total operative time was 75 min and the blood loss
was minimal. The patient was discharged a day
after the surgery with drains in situ which were
removed on the 2th postoperative day.
Discussion
Spigelian hernia is a rare ventral hernia( 3 ) .
Although paediatric Spigelian hernias have been
descr bed,4,5 this hernia usually occur in patients
over the age Bilateral Spigelian hernia treatment of
50 years, with men and women being equally affec-
t e d( 6 ).Spigelian hernia occurs from a defect in the
aponeurosis of the transverse abdominis muscle,
lateral to the rectus sheath.
The most common location of Spigelian her-
nia is at or near the junction of linea semilunaris
and the arcuate line. The arcuate line marks an ana-
tomic transition point below which all the aponeu-
rotic layers of the abdominal muscles, except the
transversalis fascia, pass anterior to the rectus abdo-
minis(1).
The arcuate line may be represented by a tran-
sverse line connecting both anterior superior iliac
s p i n e s( 7 ).The hernia orifice of most Spigelian her-
niae occur at, or close to, the arcuate line, as the
anterior abdominal wall here is only weakly
reinforced by slightly separated fascial bands(1).
Spigelian herniae reported in the literature
have been corrected surgically either by her-
niorrhaphy using interrupted non-absorbable sutu-
res or by tension-free mesh hernioplasty(6).
Both open and laparoscopic modalities of sur-
gery have been described for the repair of this her-
nia(8)..Recurrence after repair has also been docu-
mented(6).The mesh we have used for the repair is a
bilayered mesh hernia system. This system not only
plugs the hernia defect but also covers and reinfor-
ces the weak abdominal wall in two layers, thus
providing added strength to the abdominal muscu-
lature and diminishing the chances of recurrence.
References
1) Rehman JM, Seow CS, O’Dwyer PJ. Acase of a
Spigelian hernia at an unusually high anatomical loca -
tion. J. R. Coll. Surg. Edinb. 2000; 46: 196–7.
2) Spangen L. Spigelian hernia. World J. Surg. 1989; 13:
573– 80.
3) Larson DW, Farley DR. Spigelian hernias: repair and
outcome for 81 patients. World J. Surg. 2002; 26:
1277–81.
4) Losanoff JE, Richman BW, Jones JW. Spigelian hernia
in a child: case re p o rt and review of the literature.
Hernia 2002; 6: 191–3.
5) Levy G, Nagar H, Blachar A, Ben-Sira L, Kessler A .
P reoperative sonographic diagnosis of incarc e r a t e d
neonatal Spigelian hernia containing the testis. Pediatr.
Radiol. 2003; 33: 407–9.
6) L o s a n o ff JE, Richman BW, Jones JW. R e c u r re n t
Spigelian hernia: a case re p o rt. Am. Surg. 2003; 69:
109–10.
7) Holder LE, Schneider HJ. Spigelian hernias: anatomy
and roentgenographic manifestations. Radiology 1974;
112: 309–13.
8) Ng JW. Acase of small Spigelian hernias successfully
t reated by a simple laparoscopy assisted technique.
S u rg. Laparosc. Endosc. Percutan. Tech. 2004; 14:
300–3.
___________
Request reprints from:
Prof. ANTONINO GRAZIANO
Università degli Studi di Catania
Dipartimento di Chirurgia
Via S. Sofia, 86
95100 Catania
(Italy)
52 A. Graziano - M. Santangelo et Al
Fig.1: double mesh prosthesis